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BURNETT COUNTY LAND SERVICES <br />7410 COUNTY ROAD K, #120 <br />SIREN, WISCONSIN 54872 Jae�e l 3�-j3 <br />715-349-2109 <br />l.a.�nlCeke <br />POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) <br />NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION <br />ADDucatlon information t f VDe or rrtnt <br />Property Owner Name Property Legal Description <br />GL 1/4 1/4, S,26 ,T 8 N, R W <br />Property Owner's Mailing Address Property Site Address (if different than mailing address) <br />11 (o iMk OjVrrtt l y jVt e, I k r <br />City, State Zip Code Owner's Phone Number City, 3itate Zip Code <br />STi I A A N. S��1(65100-MpFrezr4 WS 59837 <br />Type of Building Being Connected: (Check one) <br />12�`Town of <br />� Q <br />9L, 1 or 2 Family Dwelling - No. of Bedrooms: ''1 <br />❑ Village <br />Eg-- Public ❑ Commercial <br />Describe uses and design flows for the building being connected: <br />Parcel Identification Number: <br />- <br />Type of Permit* <br />*A Reconnection Permit is required when a different building than was intended <br />,1� POWTS Reconnection ❑ POWTS Connection <br />for the sanitary system to serve is being connected to the system. <br />State the sanitary permit County # I C- <br />*A Connection Permit is required when the sanitary permit expired without being <br />number in question: State # I -� <br />connected to the intended use of the sanitary system, and now the building is being <br />connected. <br />Responsibility Statement: <br />I, the undersigned, assume res onsibili fort the POWTSactivity for which t ' ermit is issued. <br />P-tumber's Name (print) Plum r Si a (MP/MPRSW No.: Business Phone Number: <br />�i � r-, <br />Plumber's Address (Street, City, State, Zip Code): <br />Office Use Only: <br />proved <br />❑ Disapproved <br />❑ Owner Given Reason for <br />Fee Collected: <br />i � Oo <br />DSPS Cred. No. <br />1431555 <br />1� <br />in <br />;,ng�Rtu <br />Disa roval in Writin <br />Comments: <br />Conditions of Approval /Reasons for Disapproval: <br />rcaVT-T�rlacnsaisa <br />R <br />CLand <br />!�v�urnett Countyervices Depart <br />